Factors significantly contributing to a failed conventional endoscopic stone clearance in patients with "difficult" choledecholithiasis: a single-center experience

PREDICTORS OF FAILURE OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN CLEARING BILE DUCT STONES DURING INDEX PROCEDURE - A PROSPECTIVE STUDY

BACKGROUND

Common bile duct (CBD) stones are known to complicate 10-15% of gallstone diseases. Endoscopic retrograde cholangiopancreatography (ERCP) is the therapeutic modality of choice for bile duct clearance in CBD stones but may fail to achieve stone clearance. This prospective study was done to identify the predictors of failure of CBD clearance with ERCP.

OBJECTIVE

This prospective study was done to identify the predictors of failure of CBD clearance with ERCP.

METHODS

All consecutive patients with bile duct stones undergoing ERCP at a tertiary care center were prospectively included from October 2020 to October 2021. The study's primary outcome was to identify and analyze factors that could predict the failure of complete CBD clearance.

RESULTS

A total of 120 patients (50.8% males, median age: 53.5 years) were included in the final analysis. Successful clearance of CBD stones during the index procedure was achieved in 70% of patients. At a cut-off stone diameter of >10.5 mm and CBD diameter of >12.5 mm, the AUC was 0.890 and 0.884, respectively, to predict failed clearance of CBD. On multivariate analysis, stone diameter ≥15 mm [odds ratio (OR) 16.97, 95% confidence interval (CI): 1.629-176.785], location of stones in hepatic ducts (OR 7.74, 95%CI: 2.041-29.332), presence of stricture distal to stone (OR 6.99, 95%CI: 1.402-34.726) and impacted stone (OR 21.61, 95%CI: 1.84-253.058) were independent predictors of failed bile duct clearance.

CONCLUSION

Stone size and location are independent predictors of failed bile duct clearance. The endoscopist should consider these factors while subjecting a patient to biliary ductal clearance to plan additional intervention.

BACKGROUND

• Failure to clear bile duct stones in the index ERCP can be seen in 15-20% of cases, and identifying the factors associated with failure is important.

BACKGROUND

• A prospective analysis was conducted to identify and analyze the factors that could predict the failure of complete CBD clearance.

BACKGROUND

• The present study reported a successful clearance of CBD stones during the index procedure in only 70% of patients.

BACKGROUND

• A stone diameter ≥15 mm, location of stones in hepatic ducts, presence of stricture distal to stone, and impacted stone were independent predictors of failed bile duct clearance.

Laparoscopic Common Bile Duct Clearance, is It Feasible and Safe After Failed Endoscopic Retrograde Cholangiopancreatography?

Introduction: Concomitant gallstones and common bile duct (CBD) stones is a common problem, and there is still no consensus on the best approach in the management. Options include preoperative endoscopic retrograde cholangiopancreatography (ERCP), Laparoscopic cholecystectomy (LC) with CBD exploration, and LC with postoperative ERCP. Each option has its own limitations and complications. In this article, we assessed the feasibility of laparoscopic surgical clearance of the CBD after a failed ERCP, reasons for failure of endoscopic clearance in our cohort. We will discuss the management options after ERCP failure, the challenges, and the outcomes. Materials and Methods: We retrospectively reviewed all the cases of laparoscopic common bile duct exploration (LCBDE) performed in our hospital between April 2006 and January 2019. Two hundred cases were performed, 178 cases as a primary procedure while 22 were performed as a secondary procedure after failed ERCP. We have previously published data on the case series (PMID 33140155) and here explored the cases performed after failed ERCP as a secondary procedure. We analyzed demographics of patients, preoperative investigations, ERCP trials, and reasons for ERCP failure, operative approach, duration of operation, conversion rate, complications, and outcomes. Results: Twenty-two patients underwent a laparoscopic CBD clearance after failed ERCP. Sixteen of these were in the first 5 years of the study. Multiple attempts of ERCP were made in 7 patients (31.8%) and a single attempt in 15 patients. In 8 patients (32%), the duct was not accessible (failed cannulation) due to a variety of reasons. Nine patients had impacted stones larger than 1 cm, 4 patients had Mirrizi syndrome with concomitant large CBD stones, and 1 patient failed endoscopic clearance because of the large number of stones in the CBD. CBD clearance was successful in 19 patients (88%), 8 were completed by a transcystic approach and 14 by a transcholedochal approach. Postoperative length of stay was 12 (+10) days. One patient had an unplanned readmission within 30 days. One patient required reoperation for bleeding. Three patients developed recurrent stones and 1 developed a subsequent stricture. No mortalities were recorded. Conclusion: LCBDE is feasible and appears safe as a secondary procedure after failed ERCP. The new technologies and the advancement of surgical techniques will continue to improve success and reduce morbidity.

Development of clinical prediction rule for the requirement of endoscopic papillary large balloon dilation (EPLBD) on endoscopic CBD stone clearance

INTRODUCTION

To develop a simplified scoring system for clinical prediction of difficulty in CBD stone removal to assist endoscopists working in resource-limited settings in deciding whether to proceed with an intervention or refer patients to a center capable of performing additional procedures and interventions.

METHODS

This study included patients with CBD stones who underwent ERCP at Pattani Hospital between August 2017 and December 2021. Retrospective cohort data was collected and patients were categorized into two groups: bile duct stones successfully treated by endoscopic biliary sphincterotomy and extraction compared to the former method combined with EPLBD. We explored potential predictors using multivariable logistic regression. The chosen logistic coefficients were transformed into a scoring system based on risk with internal validation via bootstrapping procedure.

RESULTS

Among the 155 patients who had successful endoscopic therapy for bile duct stones, there were 79 (50.97%) cases of endoscopic biliary sphincterotomy, EPLBD and extraction versus 76 (49.03%) cases without EPLBD. The factors used to derive a scoring system included the size of CBD stones >15 mm, the difference between the stone and distal CBD diameter >2mm, distal CBD arm length <36 mm and stone shape. The score-based model's area under ROC was 0.88 (95% CI: 0.83, 0.93). For clinical use, the range of scores from 0 to 16, was divided into two subcategories based on CBD stone removal difficulty requiring EPLBD to derive the PPV. For scores <5 and ≥ 5, the PPV was 23.40 (p <0.001) and 93.44 (p <0.001) respectively. The Bootstrap sampling method indicated a prediction ability of 0.88 (AuROC, 95% CI: 0.83, 0.94).

CONCLUSION

This scoring system has acceptable prediction performance in assisting endoscopists in their choice of stone removal procedure.

Common bile duct stone-related parameters and their potential prognostic values for stone extraction requiring endoscopic papillary large balloon dilation

Background and Aim

For difficult common bile duct (CBD) stones, endoscopic sphincterotomy accompanied by endoscopic papillary large balloon dilatation (EPLBD) may be the preferred initial procedure according to the selection criteria. The purpose of this study was to determine the association between CBD stone-related parameters and their potential prognostic values for technically difficult CBD stone extraction requiring EPLBD.

Methods

We retrospectively analyzed the data of 80 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), endoscopic biliary sphincterotomy, or the aforementioned procedures combined with EPLBD, resulting in successful CBD stone extraction in the first session from January 2018 and December 2021. The association between CBD stone-related parameters and stone extraction requiring EPLBD was analyzed by multivariable risk regression analysis.

Results

In multivariable analysis, the independent predictors of CBD stone extraction that required EPLBD were CBD stones larger than distal CBD diameter by >2 mm (risk ratio [RR] 2.34, 95% CI 1.30-4.19) and the presence of shaped stones (round shape RR 1.69 [95% CI 1.05-2.73]; square shape RR 2.34 [95% CI 1.24, 4.44] vs oval shape).

Conclusion

Endoscopic CBD stone removal is technically difficult in patients with stones larger than 2 mm in diameter in comparison to the distal CBD diameter or round or square-shaped stones.

Predictors of failure of endoscopic retrograde pancreatocholangiography during common bile duct stones

Introduction

Endoscopic retrograde cholangiopancreatography associated with sphincterotomy and stone extraction with balloon or Dormia basket represents the gold standard for the management of common bile duct stones. The aim of our study were to investigate the predictors of failure of standard endoscopic techniques during the management of common bile duct stones.

Methods

A retrospective study including all endoscopic retrograde cholangiopancreatography for common bile duct stones between January 2014 and December 2017 was conducted. First line treatment was based on endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and balloon or Dormia extraction. Second line endoscopic treatment was based on macrodilatation of Oddi sphincter, mechanical lithotripsy, biliary stent or nasobiliary drain placement. Predictors of failure of standard endoscopic techniques were sought by uni and multivariate analysis (SPSS software, p significant if < 0.05).

Results

One hundred eighty one patients (mean age 64 years and sex ratio M/W = 0.4) were included. Main indications for endoscopic retrograde cholangiopancreatography were residual or recurrent lithiasis (67.4%, n = 122). Cholangiography revealed multiple stones in 53 patients with an average size of 12.5mm [3–40]. The success rate of first line treatment was 61.9%. Independent predictors of failure of standard endoscopic techniques (failure of papillary cannulation or stone extraction) according to multivariate analysis were: an age greater than 65 years OR 0.516 [0.272–0.979], an intra-diverticular papilla OR 0.179 [0.035–0.914], a common bile duct diameter greater than 15 mm OR 0.161 [0.068–0.385] and a stenosis of the common bile duct OR 0.068 [0.008–0.605]. The success rate of the second line treatment was 73%.

Conclusion

Endoscopic retrograde cholangiopancreatography results in a successful clearance of the common bile duct in almost two-thirds of patients. In case of predictors of failure, alternative techniques can increase this rate.

Laparoscopic Exploration of the Common Bile Duct: A Systematic Review of the Published Evidence Over the Last 10 Years

INTRODUCTION

Endoscopic and open surgical interventions are widely implemented as the standard practice in common bile duct exploration. However, the laparoscopic approach has been also reported to have comparative/superior outcomes in this concept. This has created an ongoing debate about the ideal approach to adopt in practice.

METHODS

A systematic review of the published evidence over the last decade that has looked into the outcomes of laparoscopic exploration of the common bile duct through transductal and transcystic approaches.

RESULTS

Our systematic review included 36 relevant papers. The majority were based on nonrandomized protocols conducted in single centers with high expertise. The data analysis showed that laparoscopic common bile duct exploration through both approaches was successful in more than 84% of the patients, with an average length of hospital stay of 5.6 days. Conversion to open surgery was reported in 5%-8% of the patients, and the bile leak rates from the more recent studies was 0%-12%, with mortality figures of 0%-1.3%. The outcomes were statistically in favor of the transcystic route when compared to the transductal route from the viewpoints of bile leak rates, mean operative time, duration of hospital stay and morbidity.

CONCLUSION

In experienced hands, both laparoscopic approaches in common bile duct exploration are safe in patients who are clinically fit to have this intervention. It is associated with a statistically significant lower overall morbidity and shorter duration of hospital stay when compared to open surgery. Relevant up-to-date high-quality randomized trials are unavailable.

Efficacy of endoscopic ultrasound after removal of common bile duct stone

Objective: Endoscopic retrograde cholangiopancreatography (ERCP) is a standard procedure for choledocholithiasis. Nonetheless, the recurrence rate remains quite high. This study aimed to investigate the prevalence and related factors of remnant biliary stone or sludge using endoscopic ultrasound (EUS) after the removal of common bile duct (CBD) stone and to evaluate the long-term clinical outcomes. Methods: A prospective study enrolling a consecutive series of patients who underwent ERCP for CBD stone removal was performed between June 2014 and November 2015. Following confirmation of complete CBD stone removal by the operator, EUS was performed to determine whether biliary stone or sludge remained. Patients underwent cholecystectomy if a gallstone was identified and were subsequently followed up at a regular interval of 3-6 months. We investigated whether symptomatic recurrence would occur. Results: A total of 130 patients were enrolled. The presence of remnant biliary stone or sludge after ERCP was confirmed in 36.9% (48/130) of patients. Acute angulation of the distal CBD was the sole factor associated with remnant biliary stone or sludge (p < .01). During the follow-up period, the overall recurrence rate was 17.7% (23/130). Recurrent symptomatic choledocholithiasis was predicted by remnant biliary sludge and large CBD diameter in multivariate analysis. Conclusions: Acute angulation of the distal CBD was associated with remnant biliary stone or sludge after ERCP. Remnant biliary sludge on EUS and large CBD diameter were strong predictors of symptomatic recurrence. EUS evaluation following CBD stone removal could be an effective strategy in the treatment of choledocholithiasis.

Predictors of failure of endoscopic retrograde cholangiography in clearing bile duct stone on the initial procedure

BACKGROUND/AIMS

The aim of this study is to predict cases where the clearance of the biliary system from stones at the initial endoscopic retrograde cholangiopancreatography (ERCP) might be of value for better risk-stratifying patients. We attempted to identify factors that are associated with a higher failure rate of clearing the biliary system on the index ERCP.

PATIENTS AND METHODS

This is a retrospective study from January 2008 to January 2015. All patients with bile duct stones confirmed on ERCP were included in this study. Patients who had prior attempts of bile duct stone extraction were excluded.

RESULTS

A total of 554 ERCPs were performed to extract biliary duct stones from 426 patients. The mean age was 46.3 years and 41.7% were males. The group where the index ERCP did not clear the biliary system tended to be older (50.4 vs. 45.2 years, P = 0.03). On multivariate analysis, the presence of fever (OR 4.64; 95% CI, 1.66-12.79), a larger number of filling defects (OR 1.34; 95% CI, 1.13-1.93), presence of a stricture distal to a stone (OR 4.63; 95% CI, 1.36-15.78), the use of an extraction basket (OR 3.23; 95% CI, 1.56-6.74), and/or mechanical lithotripsy (OR 3.05; 95% CI, 1.10-8.49) were all associated with a lower odds of clearing the biliary system. The use of an extraction balloon was associated with the success of clearing the biliary system (99.7% vs. 77.4%, P < 0.01) and a lower odds of failing (OR 0.01; 95% CI, 0.00-0.08) on multivariate analysis.

CONCLUSION

A few of the characteristics that are found on cholangiography at the index ERCP could be used to identify patients that might require more than one ERCP to clear the biliary system from stones.

Endoscopic Management of Difficult Bile Duct Stones

PURPOSE OF REVIEW

In 10-15% of the cases, conventional methods for removing bile duct stones by ERCP/balloon-basket extraction fail. The purpose of this review is to describe endoscopic techniques in managing these "difficult bile duct stones."

RECENT FINDINGS

Endoscopic papillary large balloon dilation with balloon extraction ± mechanical lithotripsy is the initial approach used to retrieve large bile duct stones. With advent of digital cholangioscopy, electrohydraulic and laser lithotripsy are gaining popularity. Enteroscopy-assisted or laparoscopic-assisted approaches can be used for those with gastric bypass anatomy. Difficulties in removing bile duct stones can be related to stone-related factors such as the size and location of the stone or to altered anatomy such as stricture in the bile duct or Roux-en-Y anatomy. Several endoscopy approaches and techniques have described in the recent past that have greatly enhanced our ability to remove these "difficult" bile duct stones.

Novel use of a balloon dilatation catheter to enable mechanical lithotripsy of difficult common bile duct stones after initial failed attempt: A case report

INTRODUCTION

Difficult and large common bile duct stones can be crushed and removed using a mechanical lithotripter. Very often the lack of working space within the common bile duct causing the failure of mechanical lithotripsy would inevitably mean repeat or further invasive procedures.

PRESENTATION OF CASE

A patient with large and multiple common bile duct stones underwent ERCP, and initial deployment of a mechanical lithotripter failed due to the lack of working space within the common bile duct. A through-the-scope (TTS) dilator was utilized to increase the working space before successful deployment of the mechanical lithotripter, and subsequent clearance of all stones within the same setting.

DISCUSSION

We herein describe a novel and ingenious technique of utilizing a through-the-scope (TTS) dilator in helping to expand the space within the common bile duct to allow for full deployment of a mechanical lithotripter and successful clearance of common bile duct stones. This method can be easily applied by advanced endoscopists and is expected to lead to increased success rates of difficult common bile duct stones clearance in a single setting.

CONCLUSION

Use of TTS dilators to increase working space within the common bile duct can be useful in increasing the success rates of mechanical lithotripsy in the setting of large and multiple common bile duct stones.

Efficacy and safety of novel digital single-operator peroral cholangioscopy-guided laser lithotripsy for complicated biliary stones

Background/study aims Laser lithotripsy can effectively fragment complicated biliary stones, but current cholangioscopes are limited by fragility, restricted mobility or moderate visual resolution. The efficacy and safety of a new digital single-operator peroral cholangioscope to guide laser lithotripsy were evaluated. Patients and methods In this prospective single-center series, consecutive patients with complicated biliary stones, defined as impacted stones > 1.5 cm in size and wider than the more distal common bile duct, or stones that failed extraction by basket mechanical lithotripsy, underwent ERCP and SpyGlass DS peroral cholangioscope (Boston Scientific, Marlborough, United States)-guided laser lithotripsy. Stone clearance rate and incidence of adverse events were determined. Results Seventeen patients (10 men, 7 women; median age 76 years) with a median biliary stone size of 2 cm underwent predominantly holmium:yttrium aluminum garnet laser lithotripsy, achieving a 94 % stone clearance rate over 1 median procedure. Lithotripsy was performed in 8 of 17 patients due to an impacted biliary stone. The remaining patients underwent lithotripsy due to prior failure of the basket mechanical lithotripter to capture or crush their stones. Post lithotripsy, 2 patients developed cholangitis and 1 patient with underlying COPD developed respiratory distress, all resolved with conservative management. There were no hemobilia, perforations, pancreatitis nor any deaths. Conclusion SpyGlass DS peroral cholangioscopy-guided laser lithotripsy is an efficient and safe modality for management of complicated biliary stones.